When a woman is given a cancer diagnosis, her entire world is turned upside down and inside out. There are so many things to think about; medical treatments, financial concerns, family concerns, and emotional upheaval. Sex may be the last thing that a woman may think about when she is actively going through treatment. However, at what rate are survivors having issues after treatment is complete?
A recent study published in the journal Cancer looked at just this. A 2-year longitudinal study was performed that tracked young adults (18-39 years old) through and after their cancer diagnosis. The most common cancers seen in the samples were leukemia, breast cancer, soft-tissue sarcoma, and non-Hodgkin lymphoma. The patients completed the Medical Outcomes Study Sexual Functioning Scale at 4 months, 6 months, and 24 months after diagnosis. At 2 years after diagnosis over 50% of the patients surveyed reported some degree of sexual dysfunction. Women that were in a committed relationship had an increased likelihood for experiencing sexual dysfunction; while men had increased rate of reporting sexual issues regardless of their relationship status.
Women that undergo cancer treatment have several reasons that could be influencing their sexual function. Fatigue is a complaint that is often expressed by cancer patients. Their body image is often altered due to surgeries that have been performed. Chemotherapy and hormonal therapy often push women into menopause which then leads to vaginal dryness. Additionally, radiation and surgical treatment can lead to scar tissue, fibrosis, and stenosis of the vagina and pelvic floor muscles.
This is where physical therapy can help! In the Pelvic Floor Series Capstone course we teach advanced techniques that help treat pelvic floor issues by working on both the muscles, and the fascia. We also cover techniques that decrease the tenderness in the muscles that then allow you to stretch the muscle with less discomfort.
All of the techniques taught in Capstone are gentle but effective. The cancer survivor is the perfect population to use these gentle techniques on! Think of how rewarding our job will be when we help relieve the pain that may be associated with intercourse, and therefore improve intimacy of a cancer survivor with her partner!
Come join us for Capstone and learn techniques that will take your treatment skills to the next level!
Acquati, Zebrack, Faul, et al. Sexual functioning among young adult cancer patients: A 2-year longitudinal study. Cancer. 2018; 124(2): 398-405.
The Center for Disease Control reports that prostate cancer is the most common form of male cancer in the United States (just ahead of lung cancer and colorectal cancer), and the American Cancer Society estimates that 1 in 7 men will be diagnosed with prostate cancer at some point in their lifetime. With prostate cancer being so common, it is likely that a male with symptoms of urinary incontinence following a prostatectomy may show up at your clinic’s door for treatment. What do you do? Whether you have extensive training for male pelvic floor disorders or are just starting your initial training for pelvic floor dysfunctions, you likely have some intervention skills to help this population.
A recent case report in the Journal of Women’s Health Physical Therapy, outlines management of a 76-year-old male patient with mixed urinary incontinence postprostatectomy 10 years. This case report does a nice job describing not just physical therapy (PT) interventions, but also multifaceted management of a typical patient post radical prostatectomy. The case report describes a thorough history, systems review, pelvic floor muscle (PFM) examination, tests &measures, and outcome assessment. Our discussion will focus on interventions as you may already possess the skills for several of the treatments included in this patient’s plan of care.
The patient’s complaints were mixed urinary incontinence (UI) symptoms including 3-4 pads per day and 1 pad at night. He reported nocturia 3-4 times per night. 2-3 times per week he had large UI episodes that soaked his outwear. Also, he complained of inability to delay voiding, and UI with walking to the bathroom, sit to stand, lifting, coughing, and sneezing.
For the patients’ urge UI symptoms, behavioral interventions were utilized. The patient completed PFM contractions to inhibit detrusor contractions and suppress urgency (urge control technique). Educating the patient on correct PFM contraction isolation was a very important component of this patients’ treatment. Verbal, digital, and surface electromyography (sEMG) techniques were used to ensure correct PFM contraction and to reduce Valsalva. Clinical decision making for home exercise program utilized dominant PFM fiber types and the patients’ performance on the PERFECT PFM strength testing system described by Laycock. (External Urethral Sphincter is predominantly Type II fast twitch muscle fiber in males and Levator Ani is predominantly Type I slow twitch.) For the home program, the patient completed progressive reps and sets of 10” (targets slow twitch) and 2” (targets fast twitch) PFM isometrics in supine progressing to standing. (There is a chart with additional details on PFM home program for each visit in the case report.) Additionally, instruct and use of “the knack” (volitional PFM contraction before and during cough or other physical exertions to prevent UI) for activities that the patient usually had UI with including sit to stand transfer, lifting, coughing, and sneezing was essential for the patients’ symptoms. PFM coordination training with sEMG helped reduce his accessory muscle recruitment patterns and Valsalva. Bladder retraining and lifestyle recommendation were important (per his 3-day bladder diary) as he was consuming 3 cups of coffee and 4 cups or more of tea a day, likely contributing to urgency and urge UI symptoms. Also, he was informed regarding the effect of obesity on UI (as his BMI was 35.9 placing him in the obese range) and that modest amounts of weight loss maybe sufficient for UI reduction. Abdominal exercises targeting Transversus Abdominus were also prescribed for their role in core support with PFM’s. Lastly, electrical stimulation was not included in this patients’ plan of care due to the patients’ cardiac history and pacemaker, as well as, he could initiate PFM contraction and utilize urge control techniques appropriately.
The outcome for this patient was positive. He attended 5 PT sessions over a 3-month period. He did have to cancel two appointments between the 4th and 5th visits due to an emergency surgery to place two cardiac stents. He had reduced urinary leakage indicated by reduced undergarment changes and reduced pad usage per day. His pads were less saturated and he no longer had leakage that spread to his outwear. He had a 50% reduction in UI episodes reported on his bladder diary and a 50% reduction in nocturia from 4 times to 2 times per night. He reported reduced daily urinary frequency from 7 to 5 times per day with no instances of severe urgency. He demonstrated improved PERFECT score of 4, 10, 8, 10 (initially his score was 2, 5, 3, 5) indicating improved PFM strength and endurance. Also, he had improved PFM coordination as he could isolate PFM contraction without Valsalva or accessory muscle activation. He also had one strength grade improvement with abdominal strength. All that being said, most importantly, this patient had improved rating on the outcome questionnaire (International Continence Society male Short Form (ICSmaleSF)) at discharge indicating improved quality of life. At initial evaluation, this patient rated “a lot” (3 on ICSmaleSF) when asked how much the urinary symptoms interfered with his life, at discharge he reported “not at all” (0 on ICSmaleSF).
One component to this case that I found fascinating was the duration of time that had passed since this patients’ prostatectomy. It had been 10 years since this patient had his surgical procedures. He had never been offered physical therapy or knew about it as a possible treatment for his symptoms. Additionally, that he could have such success with improvements in voiding and incontinence function, as well as improved quality of life as long as 10 years’ post-prostatectomy.
This case report is a comprehensive glimpse of what physical therapy assessment and treatment may look like for a patient with urinary dysfunction following radical prostatectomy. This patient had great improvements with positive changes enhancing his quality of life. So, if you are considering adding treatment of this population to your practice consider attending Post-Prostatectomy Patient Rehabilitation, available this July in Annapolis, MD or September in Seattle, WA.
"Cancer Among Men", Centers for Disease Control and Prevention
Roscow, A. S., & Borello-France, D. (2016). Treatment of Male Urinary Incontinence Post–Radical Prostatectomy Using Physical Therapy Interventions. Journal of Women’s Health Physical Therapy, 40(3), 129-138.
A recent systematic review published in The Lancet online describes the benefits of using music as a postoperative aid in recovery. Seventy-three randomized, controlled trials were included in the review, and the articles covered the use of music before, during, and after surgery. A wide variety of surgical procedures were represented in the research articles, and included cardiac procedures, mastectomy, urogynecologic and abdominal surgeries, and gastrointestinal surgeries and procedures. Interventions included listening to music with headphones, listening to relaxation training or “therapeutic suggestion.” Many of the studies included a control group with routine care or white noise, headphones without music.
The main results of the research is that use of music reduces postoperative pain, anxiety, and analgesia use, and improves patient satisfaction. The timing of or choice of music listened to in the studies did not significantly affect outcomes. Interestingly, even when patients were given general anesthesia, music was effective. And when patients chose their own music, there was a slight increase in reduction of pain and analgesia use.
How can this information be of use to pelvic rehabilitation providers? Perhaps one of your patients will be heading into surgery. A recommendation for listening to favorite music in the postoperative period could be made. Is music available to your patients in your setting? If so, what kind of music? Is the patient allowed to influence the type of music? Maybe the patient could play a favorite song list from their smart phone, or request a certain time period of music on a music subscription service you may use in the clinic. Regardless of how we use this information, it’s great to be reminded of the potentially positive ways that music can influence healing.
National Public Radio (NPR) recently posted a story on their website that you can listen to if you are interested. For more interesting reads about music and healing, check out the links below: